Febrile Seizures in the ED: Hot and Bothered

-Case-

It’s late at night when the parents of a 2-year-old boy rush him into the ED. He had a fever earlier in the evening, and while they were getting him ready for bed, he suddenly stiffened, his eyes rolled back, and he started convulsing. It lasted about two minutes before stopping on its own. Now, he is postictal but slowly perking up. 

  • Key Red Flags to Consider: is this a seizure disorder vs meningitis vs intracranial pathology, or is it simply a febrile seizure?

-Evaluation-

  • Febrile seizures are the most common seizure disorder in kids (2-5%), typically occurring in children in ages 6 months – 5 years
  • Types:
    • Simple: Generalized, <15 min, no recurrence in 24 hours → Benign, no ↑ epilepsy risk
    • Complex: >15 min, focal, or recurrent within 24 hours → Requires further evaluation
  • When do we worry?
    • Prolonged seizure (>5 min)
    • Child outside the classic age range
    • Focal deficits present on exam
    • Persistent altered mental status
    • Concern for a CNS infection? Consider LP, neuroimaging, EEG!

-Management-

  • Simple febrile seizures:
    • Parental reassurance (this presentation is both benign and self-limiting!)
    • Treat fever source (commonly an otitis media, or viral illness)
    • Antipyretics (comfort measure only; unfortunately this does not prevent seizures)
  • Complex febrile seizures:
    • Consider admission + further workup to rule out infection, structural abnormality
    • Abortive therapy is needed for prolonged seizures; benzos are key if the seizure lasts >5 min!

-Fast Facts-

  • Classic presentation of a febrile seizure = fever + brief, generalized seizure in child aged 6 months – 5 years
  • Minimal workup needed if reassuring history & normal exam
  • Antipyretics do not prevent seizures
  • Parental education is crucial; calm their fears and emphasize the benign nature!

Febrile seizures are more alarming for parents than for the child. Not every febrile seizure needs an extensive workup; sometimes, the best medicine is education and reassurance!

Want to learn more? Read our in-depth febrile seizures study guide!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Patel AD, Vidaurre J. Complex febrile seizures: A practical guide to evaluation and treatment. Epilepsy Behav. 2013;28(3):304–309. doi:10.1016/j.yebeh.2013.05.020
  2. Offringa M, Newton R, Nevitt SJ. Prophylactic drug management for febrile seizures in children. Cochrane Database Syst Rev. 2017;2(2):CD003031. doi:10.1002/14651858.CD003031.pub3
  3. Huff JS, Melnick ER, Tomaszewski CA, et al. Clinical policy: Critical issues in the evaluation and management of adult patients presenting to the emergency department with seizures. Ann Emerg Med. 2014;63(4):437–447.e15. doi:10.1016/j.annemergmed.2013.11.005
  4. Steering Committee on Quality Improvement and Management, Subcommittee on Febrile Seizures. Febrile seizures: Clinical practice guideline for the long-term management of the child with simple febrile seizures. Pediatrics. 2008;121(6):1281–1286. doi:10.1542/peds.2008-0939
  5. Kimia AA, Capraro AJ, Hummel D, et al. Utility of lumbar puncture for first simple febrile seizure among children 6 to 18 months of age. Pediatrics. 2009;123(1):6–12. doi:10.1542/peds.2007-3421
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